Regards timing of health insurer recoupment from providers

sb162_05_EN

(136th General Assembly)

(Amended
Substitute Senate Bill Number 162)

AN
ACT

To amend section 3901.388 of
the Revised Code regarding the timeframe for health insurer
recoupment from health care providers.

Be
it enacted by the General Assembly of the State of Ohio:

Section
1.
That

section

3901.388
of the Revised Code be amended to read as follows:

Sec.
3901.388.
(A)
A
payment made by a third-party payer to a provider in accordance with
sections 3901.381 to 3901.386 of the Revised Code shall be considered
final
two
years
one
year

after payment is made. After that date, the amount of the payment is
not subject to adjustment, except in the case of fraud by the
provider.

(B)
A third-party payer may recover the amount of any part of a payment
that the third-party payer determines to be an overpayment if the
recovery process is initiated not later than
two
years
one
year
after
the payment was made to the provider. The third-party payer shall
inform the provider of its determination of overpayment by providing
notice in accordance with division (C) of this section. The
third-party payer shall give the provider an opportunity to appeal
the determination

and
shall not charge the provider a fee for an appeal
.
If the provider fails to respond to the notice
sooner
than thirty
within
sixty
days
after the notice is made,

elects
not to appeal the determination,

or appeals the determination but the appeal is
not
upheld
denied
,
the third-party payer may initiate recovery of the overpayment.

When
a provider has failed to make a timely response to the notice of the
third-party payer's determination of overpayment, the third-party
payer may recover the overpayment by deducting the amount of the
overpayment from other payments the third-party payer owes the
provider or by taking action pursuant to any other remedy available
under the Revised Code. When a provider
elects
not to appeal a determination of overpayment or
appeals
the determination but the appeal is
not
upheld
denied
,
the third-party payer shall permit a provider to repay the amount by
making one or more direct payments to the third-party payer or by
having the amount deducted from other payments the third-party payer
owes the provider.

(C)
(C)(1)

The notice of overpayment a third-party payer is required to give a
provider under division (B) of this section shall be made in
writing

accordance
with division (C)(2) of this section
and
shall specify all of the following:

(1)
(a)

The full name of the beneficiary who received the health care
services for which overpayment was made;

(2)
(b)

The date or dates the services were provided;

(3)
(c)

The amount of the overpayment;

(4)
(d)

The claim number or other pertinent numbers;

(5)
(e)

A detailed explanation of basis for the third-party payer's
determination of overpayment;

(6)
(f)

The method in which payment was made, including, for tracking
purposes, the date of payment and, if applicable, the check number;

(7)
(g)

That the provider may appeal the third-party payer's determination of
overpayment, if the provider responds to the notice within
thirty

sixty

days;

(8)
(h)

The method by which recovery of the overpayment would be made, if
recovery proceeds under division (B) of this section.

(2)
A third-party payer shall give a provider a notice of overpayment in
writing. If the third-party payer and provider use an agreed-upon
established electronic notification system, the third-party payer
shall notify the provider electronically through that system.

(D)
Any provision of a contractual arrangement entered into between a
third-party payer and a provider or beneficiary that is contrary to
divisions (A) to (C) of this section is unenforceable.

Section
2.
That
existing
section

3901.388
of the Revised Code
is

hereby
repealed.

Speaker
___________________ of the House of Representatives.

President
___________________ of the Senate.

Passed
________________________, 20____

Approved
________________________, 20____

Governor.

The section numbering of law
of a general and permanent nature is complete and in conformity with
the Revised Code.

Director, Legislative
Service Commission.

Filed
in the office of the Secretary of State at Columbus, Ohio, on the
____ day of ___________, A. D. 20____.

Secretary of State.

File
No. _________ Effective Date ___________________